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A single dose produces (Pentothal) sively in general anesthesia; excellent hypnotic unconsciousness in less than 30 seconds and but does not produce significant analgesia or lasts 20–30 minutes generic 160mg malegra dxt plus fast delivery. Usually given to induce anes- muscle relaxation; given IV by intermittent injec- thesia buy 160mg malegra dxt plus otc. For major surgery 160mg malegra dxt plus amex, it is usually supplemented by inhalation anesthetics and muscle relaxants 160mg malegra dxt plus with mastercard. Se- other disorders are also involved malegra dxt plus 160 mg without prescription, the risks of anesthesia and vere anxiety, for example, may be a contraindication to re- surgery are greatly increased. Because of the risks, general gional anesthesia, and the client may require larger doses of anesthetics and neuromuscular blocking agents should be preanesthetic sedative-type medication. General Anesthesia General anesthesia can be used for almost any surgical, diag- Regional and Local Anesthesia nostic, or therapeutic procedure. If a medical disorder of a vital organ system (cardiovascular, respiratory, renal) is present, it Regional or local anesthesia is usually safer than general should be corrected before anesthesia, when possible. For CHAPTER 14 ANESTHETICS 225 TABLE 14–2 Neuromuscular Blocking Agents (Skeletal Muscle Relaxants) Generic/Trade Name Characteristics Uses Depolarizing Type Succinylcholine (Anectine) Short acting after single dose; action can be pro- All types of surgery and brief procedures, such as endoscopy longed by repeated injections or continuous and endotracheal intubation intravenous infusion. Nondepolarizing Type Atracurium (Tracrium) Intermediate acting* Adjunct to general anesthesia Cisatracurium (Nimbex) Intermediate acting* Same as rocuronium, below Doxacurium (Nuromax) Long acting* Adjunct to general anesthesia Metocurine (Metubine) Long acting; more potent than tubocurarine* Same as vecuronium, below Mivacurium (Mivacron) Short acting* Adjunct to general anesthesia Pancuronium (Pavulon) Long acting* Mainly during surgery after general anesthesia has been induced; occasionally to aid endotracheal intubation or mechanical ventilation Pipecuronium (Arduan) Long acting* Adjunct to general anesthesia; recommended only for proce- dures expected to last 90 minutes or longer Rocuronium (Zemuron) Intermediate acting* Adjunct to general anesthesia to aid endotracheal intubation and provide muscle relaxation during surgery or mechanical ventilation Tubocurarine Long acting; the prototype of nondepolarizing Adjunct to general anesthesia; occasionally to facilitate drugs* mechanical ventilation Vecuronium (Norcuron) Intermediate acting* Adjunct to general anesthesia; to facilitate endotracheal intubation and mechanical ventilation *All the nondepolarizing agents may cause hypotension; effects of the drugs can be reversed by neostigmine (Prostigmin). TABLE 14–3 Local Anesthetics Generic/Trade Name Characteristics Clinical Uses Articaine (Septocaine, Newer drug, formulated with epinephrine Local infiltration and nerve block for dental and peri- Septodont) Effects occur in 1–6 min and last 1 hour odontal procedures or oral surgery Benzocaine (Americaine) Poorly water soluble Topical anesthesia of skin and mucous membrane to Minimal systemic absorption relieve pain and itching of sunburn, other minor Available in numerous preparations, including aerosol burns and wounds, skin abrasions, earache, hemor- sprays, throat lozenges, rectal suppositories, lotions, rhoids, sore throat, and other conditions and ointments May cause allergic reactions Effects occur in 5 min or less and last 15–45 min Bupivacaine (Marcaine) Given by injection Regional anesthesia by infiltration, nerve block, and May cause systemic toxicity epidural anesthesia during childbirth. It is not used Effects occur in 5 min and last 2–4 hours with for spinal anesthesia. With injection, effects occur in 2–5 min and last 15–60 min Proparacaine (Alcaine) Causes minimal irritation of the eye but may cause Topical anesthesia of the eye for tonometry and for allergic contact dermatitis of the fingers removal of sutures, foreign bodies, and cataracts Ropivacaine (Naropin) Given by injection or epidural infusion Obstetric or postoperative analgesia and local or With epidural infusion, effects occur in 10–30 min and regional surgical anesthesia last up to 6 hours Tetracaine (Pontocaine) Applied topically Topical anesthesia Formerly injected for regional anesthesia but now rarely injected because of possible allergic reactions example, spinal anesthesia is often the anesthesia of choice for 2. Choice of a local anesthetic depends mainly on the rea- surgery involving the lower abdomen and lower extremities, son for use or the type of regional anesthesia desired. A major advantage of spinal anesthesia is that it causes topical and injectable forms. Except with IV lidocaine for cardiac dysrhythmias, of local anesthetic agents include the following: local anesthetic solutions must not be injected into 1. Local anesthetics should be injected only by people blood vessels because of the high risk of serious ad- with special training in correct usage and only in loca- verse reactions involving the cardiovascular system tions where staff, equipment, and drugs are available and CNS. To prevent accidental injection into a blood for emergency use or cardiopulmonary resuscitation. You have been asked to extend your shift because someone has called • Decreased Cardiac Output related to effects of anesthetics, in sick. You are preparing some intravenous morphine to adminis- other medications, and surgery ter to one patient, but before you administer the morphine, you are • Risk for Ineffective Breathing Patterns related to respira- interrupted twice. After you finally administer the drug, you realize tory depression that you administered it to the wrong patient. For example, ephedra increases risks of cardiac dysrhythmias, hypertension, myocardial in- Preoperatively, assist the client to achieve optimal condi- farction, and stroke; feverfew, garlic, ginkgo, and ginseng tions for surgery. Some guidelines include the following: can increase risks of bleeding; kava and valerian can in- • Provide foods and fluids to improve or maintain nutri- crease effects of sedatives. If use of local or regional anes- other vitamins, and electrolytes to promote healing). This helps promote respiratory and cardiovascular • Assess for risk factors for complications of anesthesia and function and decreases anxiety. Postoperatively, the major focus is on maintaining a safe en- vironment and vital functions. Specific interventions include: Postoperative Assessment • Observe and record vital signs, level of consciousness, res- • During the immediate postoperative period, assess vital piratory and cardiovascular status, wound status, and elim- signs and respiratory and cardiovascular function every ination frequently until sensory and motor functions return, 5 to 15 minutes until reactive and stabilizing. If potential problems are identified (eg, hypo- • Continue to assess vital signs, fluid balance, and laboratory volemia or hypervolemia), intervene to prevent them and other data. This combination should not be given IV or in exces- fever or other signs of infection). This combination should not be used with inhalation ing before injecting the local anesthetic solution.

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Phencyclidine (PCP) produces excitement cheap 160 mg malegra dxt plus with visa, delirium generic malegra dxt plus 160 mg with amex, hallu- Volatile Solvents (Inhalants) cinations purchase malegra dxt plus 160mg on-line, and other profound psychological and physiologic effects purchase malegra dxt plus 160mg fast delivery, including a state of intoxication similar to that produced These drugs include acetone discount malegra dxt plus 160 mg mastercard, toluene, and gasoline. These by alcohol; altered sensory perceptions; impaired thought solvents may be constituents of some types of glue, plastic processes; impaired motor skills; psychotic reactions; sedation cements, aerosol sprays, and other products. Some general in- and analgesia; nystagmus and diplopia; and pressor effects that halation anesthetics, such as nitrous oxide, have also been can cause hypertensive crisis, cerebral hemorrhage, convul- abused to the point of dependence. Death from overdose also has occurred often abused by preadolescents and adolescents who squeeze as a result of respiratory depression. Bizarre murders, suicides, glue into a plastic bag, for example, and sniff the fumes. Suf- and self-mutilations have been attributed to the schizophrenic focation sometimes occurs when the sniffer loses conscious- reaction induced by PCP, especially in high doses. These substances produce symptoms comparable with Phencyclidine is usually distributed in liquid or crystal form those of acute alcohol intoxication, including initial mild and can be ingested, inhaled, or injected. It is usually sprayed euphoria followed by ataxia, confusion, and disorientation. Probably be- Some substances in gasoline and toluene also may produce cause it is cheap, easily synthesized, and readily available, PCP symptoms similar to those produced by the hallucinogens, in- is often sold as LSD, mescaline, cocaine, or THC (the active cluding euphoria, hallucinations, recklessness, and loss of self- ingredient in marijuana). Consequently, the drug Substances containing gasoline, benzene, or carbon tetrachlo- user may experience severe and unexpected reactions, includ- ride are especially likely to cause serious damage to the liver, ing death. These substances produce psychological dependence, and Hallucinogen Dependence some produce tolerance. If it does occur, it is Tolerance develops, but there is no apparent physical de- considered less intense than the physical dependence associ- pendence or abstinence syndrome. Users may prefer one of these drugs, but they apparently do without or substitute another drug if the one they favor is unavailable. A major danger with these drugs is their ability to impair Nursing Process judgment and insight, which can lead to panic reactions in which users may try to injure themselves (eg, by running Assessment into traffic). Assess clients for signs of alcohol and other drug abuse, including abuse of prescription drugs, such as antianxiety Treatment of Hallucinogen Abuse agents, opioids, and sedative-hypnotics. Some general screening-type questions are appropriate for any initial There is no specific treatment for hallucinogen dependence. The overall purpose of these questions Those who experience severe panic reactions may be kept in is to determine whether a current or potential problem ex- a safe, supportive environment until drug effects wear off or ists and whether additional information is needed. Denial of excessive drinking and of • Risk for Injury: Infection, hepatitis, AIDS related to use problems resulting from alcohol use is a prominent charac- of contaminated needles and syringes for IV drugs teristic of alcoholism; underreporting the extent of drug use is common in other types of drug abuse as well. Useful in- Planning/Goals formation includes each specific drug, the amount, the fre- • Safety will be maintained for clients impaired by alcohol quency of administration, and the duration of administration. If answers to general questions reveal problem areas, such • Information will be provided regarding drug effects and as long-term use of alcohol or psychotropic drugs, more treatment resources. For nurses who often encounter substance abusers, efforts to keep up • Administer prescribed drugs correctly during acute intox- with drug names and terminology may be helpful. For example, information may be obtained that rologic functions; mental status; and behavior at regular would indicate the likelihood of a withdrawal reaction, the intervals. These disorders may include infections, liver dis- arette smoke can precipitate or aggravate asthma and ease, accidental injuries, and psychiatric problems of upper respiratory disorders in children. These disorders may be caused by • Inform smokers with nonsmoking spouses or other mem- other factors, of course, and are nonspecific. Nursing Diagnoses Evaluation • Ineffective Coping related to reliance on alcohol or other • Observe for improved behavior (eg, less impulsiveness, drugs improved judgment and thought processes, commits no • Risk for Injury: Adverse effects of abused drug(s) injury to self or others). CHAPTER 15 SUBSTANCE ABUSE DISORDERS 249 Efforts to change attitudes and decrease demand Nursing Notes: Apply Your Knowledge for drugs can be made through education and coun- seling about such topics as drug effects and nondrug ways to handle the stresses and problems of daily life. She tells you she has tried to quit smoking many times be- fore but this time she is determined. She went to her physician for drinking alcoholic beverages and taking mind-altering a prescription for the patch and she even bought some nicotine drugs. Initially, conscious, voluntary choices are made gum at the drug store in case the cravings get really bad. Since This period varies somewhat, but drug dependence de- you are an RN, as well as the mother of a friend, what advice can velops in most instances only after prolonged use. When mind-altering drugs are prescribed for a legiti- mate reason, the client must use them in prescribed doses and preferably for a short time.

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Symptoms Without Disease 89 Self-Awareness buy cheap malegra dxt plus 160 mg line, Connection to Life buy 160 mg malegra dxt plus overnight delivery, and Willingness to Explore Te method of grouping I used is not a diagnostic tool nor does it substitute for a thorough medical workup buy discount malegra dxt plus 160mg. Keep in mind that I cre- ated the groupings only after medical diagnoses had been excluded by extensive testing cheap malegra dxt plus 160mg mastercard. Te groupings describe some characteristics of a special subset of patients who presented with symptoms but who did not have a demonstrable disease to explain them cheap malegra dxt plus 160mg fast delivery. Te method also does not predict the presence or absence of psychological or social stress. Although a patient readily admits to stress (Group I) and be- lieves the stress explains the symptoms, there still needs to be a medical evaluation to exclude likely diseases. Even though in these groupings I used the timing with which patients introduced social and psychological information (that is, in their first or second vis- Table 11-1. Grouping of Patients with Symptoms Without Medical Disease Group Group Group Group I II III IV Level of self- Aware Aware Unaware Unaware awareness Level of Almost Un- Un- connection of Connected connected connected connected self to life Level of willingness to Willing Willing Willing Unwilling explore life 90 Symptoms of Unknown Origin its, or not at all), I do not mean to imply that all such patients have a psychological or social reason for their symptoms. Finding the real causative or triggering factors for any symptom takes collabo- ration between the physician and the patient. For patients who fall into Groups I, II, or even III, the collaborative effort to trace causa- tion will likely be productive. For patients with the characteristics of Group IV, the effort will be largely futile. Maybe future studies and research of this group of patients will lead to more productive approaches than I was able to find. Although I did not test the idea systematically, I found this method for grouping by awareness and connectedness to life events also useful for patients with a defined medical disease. Even though I did not subject the excluded seventy-two patients to detailed analysis, it was my experience that patients who fell into Groups I, II, or III were more amenable to examining their daily lives, even when there was a medical disease present. Tey were amenable to changing habits, making adjustments in their lives, and taking medications that the disease process required for maximum im- provement. For patients with the characteristics of Group IV, disease is a way of life whether it is objectively demonstrable or not. I believe, but cannot prove, that patients with the characteristics of Group IV will do more poorly with medical diseases than those in Groups I, II, or III. Some patients in Group IV use their diseases to manipu- late their families and friends. Tere were 165 previous surgi- Symptoms Without Disease 91 cal operations among the seventy-eight patients, an average of 2. One of the most telling aspects of this study is the number and nature of the false diagnoses carried by these patients. Table 11-2 lists the forty-two diagnoses that were not substantiated by fur- ther study. Aside from diverting the attention of patients from the real source of their problems, some of these labels are serious and harmful enough to be worthy of comment. Another patient was told the lipoma on her forearm was potentially malignant. Two patients were taking propylthiouracil for unsubstantiated hyperthyroidism. Sweet Ting was taking insulin for her misdiag- nosed diabetes and having frequent hypoglycemic episodes. One patient was referred for cobalt therapy to the pituitary gland for a false diagnosis of acromegaly. Te diagnosis was based on borderline physical findings of a large face, jaw, and hands, and a growth-hormone level at the upper limits of normal that allegedly was not suppressed with glucose administration. When I ques- tioned the patient, she said she had not received any glucose on the day of the serial measurements. An infusion of glucose produced complete suppression of her growth-hormone levels. One patient had had serial teeth extractions until all the teeth had been removed from the entire left side of her mouth. Tere were two patients on glucocorticoids for false diagnoses of thyroid- itis.

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